Plant poisoning outbreak in the western area of Cambodia, 2005.

An outbreak investigation was conducted during February-March 2005 to determine the cause of several sudden deaths occurring in Pailin Province, Cambodia. Sixty-seven patients presented with non-febrile poisoning-like symptoms and 15 died of coma, including 53% children under 10 years old. Symptoms included sore throat (92%), sore lips (73%), swollen tongue (54%) and gastrointestinal signs (41%). A plant locally called prik was the source of poisoning (97.0 vs. 28.7%, odds ratio 74.3, P<0.001). Patients may have confused the edible Melientha suavis Pierre with Urobotrya siamensis Hiepko, both from the Opiliaceae family. This was the first report of Urobotrya poisoning and its clinical manifestations.

[What are the markers of tobacco smoking?]. / Quels sont les marqueurs du tabagisme?

In this updated review of tobacco smoking markers (smokers non-smokers) in various biological environments, during varied circumstances of use, we present the parameters known to be detectable to date. The focus is placed on:--certain bio-markers used in routine practice: plasmatic, urinary or salivary cotinine end-expired carbon monoxide,--certain minor tobacco alkaloids such as anabasine and anatabine, as potential bio-markers, particularly for monitoring abstinence during nicotinic substitution therapy,-- use of superficial body growths (hair and nails) as a biological environment for measuring nicotine and cotinine to monitor exposure to environmental tobacco smoke and fetal exposure.

[What diagnostic tools can be used to assess antenatal exposure to smoking? Toxicologist experience]. / Quels sont les outils diagnostiques chez le nouveau-né de l'exposition anténatale au tabagisme? Expérience toxicologique.

Based on a review of the literature and our toxicological experience, we present the diagnostic tools available for the clinician to explore and quantify the degree of ante-natal exposure to active and passive maternal smoking. Two types of tools are used to evaluate this fetal exposure:--Repeated measurement of bio-markers of tobacco smoking enable and evaluation of the specific degree of nicotinic exposure for the pregnant women, the fetus (cord blood), the placenta and the newborn. The total fetal exposure during pregnancy can be extrapolated by combining these data. --Markers of toxicity related to active and passive maternal smoking (cadmium, cytochrome P450 CYP 1A1 activity). In the newborn, two biological tissues, meconium and hair, can be used to obtain an objective measurement of fetal exposure. Meconium concentrations of cotinine and trans-3'-hydroxycotinine correctly reflect the nicotinic practices of the mother and neonatal hair concentrations of nicotine and cotinine confirm the systemic degree of long-term exposure.

[Synthetic drugs consumed at "rave parties"]. / Drogues de synthèse consommées dans les "rave-parties".

Significant health risks result from the rising consumption of psychoactive drugs employed for festive objectives. Once alerted by this new danger, the French interministerial mission for the fight against illicit drugs and drug abuse (MILDT) set up a system of chemical and social studies in collaboration with the European Office of Drugs and Drug Abuse. The goal of the project is to discover the chemical structure of currently used drugs, and to study and predict their pharmaco-toxicaological effects. Over the last five Years, the laboratory of the Fernand Widal Hospital has analyzed more than 2,000 samples: 181 different molecules have been identified, ranging from inoffensive agents to very active drugs, including some misused licit drugs. Many of the compounds identified are amphetamine derivatives. The most widespread drug was ecstasy. Consumers and dealers seek substances with more potent psycho-stimulating effects which are not on the narcotics list and less expensive, producing effects as close to ecstasy as possible. In this extremely permissive context, other non-amphetaminic products are in circulation, including anesthesics such as ketamine and CHB, leading users to unconscious assent. The medical risks increase even more when several psychoactive substances are consumed in combination.

Trends in opiate and opioid poisonings in addicts in north-east Paris and suburbs, 1995-99.

AIMS: (1). To assess the trends in the number, mortality and the nature of severe opiate/opioid poisonings from 1995 to 1999 in north-east Paris and adjacent suburbs and (2). to examine the effects of the introduction of high-dose buprenorphine on these parameters. DESIGN: Retrospective, 5-year study with review of pre-hospital, hospital and post-mortem data. SETTING AND PARTICIPANTS: Eighty patients from the toxicological intensive care unit (TICU) in north-east Paris, 421 patients from the pre-hospital emergency medical service in a north-east suburb of Paris (SAMU 93) and 40 deaths from the coroner's office in Paris. MEASUREMENTS AND RESULTS: We found that the number of pre-hospital opiate/opioid poisonings and deaths decreased over 5 years. During the same time frame, opiate/opioid poisoning admissions to our TICU remained steady, but the number of deaths declined. From 1995 to 1999, the detection of buprenorphine among opiate/opioid-poisoned TICU patients increased from two to eight occurrences per year while detection of opiates diminished from 17 to 10 occurrences per year. Increased buprenorphine detection correlated directly with increasing sales over this time period. In spite of the increased use of buprenorphine, the mortality associated with opiate/opioid poisonings has diminished in the pre-hospital environment from 9% in 1995 to 0% in 1999, and in the TICU from 12% in 1995 to 0% in 1997 and thereafter. We found a high frequency of multiple opiate/opioid use in severe poisonings, as well as the frequent association of other psychoactive drugs including ethanol. CONCLUSIONS: The number and the mortality of opiate/opioid poisonings appear to be stable or decreasing in our region. The association of multiple opiates/ opioids appears nearly as common as the association with other psychoactive drugs. The introduction of high-dose buprenorphine coincides with a decrease in opiate/opioid poisoning mortality. Further study will be necessary to clarify this observation.

[Home environment and acute propylene glycol intoxication in a two-year old. An unusual case report]. / Environnement domestique et intoxication aiguë au propylène glycol chez un nourrisson de deux ans. A propos d'une observation inhabituelle.

BACKGROUND: Acute propylene glycol intoxication in a two-year-old toddler underlines the potentially serious toxicity in children of this chemical agent present as a diluent in many drugs and environmental products such as cosmetics, diapers, cleansing towels, despite a common consideration of safety and lack of toxicity. CASE REPORT: A two-years-old boy previously healthy was found in the morning by his parents in his cradle, lethargic, responsive only to sharp pain. On admission, vital signs were: temperature 38.5 degrees C, lethargy, polypnea; propylene glycol intoxication through disposable cleansing towels chewing was ascertained by anamnesis and blood urine analyses which revealed metabolic acidosis and serum propylene glycol peak. CONCLUSION: Environmental acute propylene glycol intoxication must be considered and searched for in front of a metabolic acidosis case of unknown origin in children.

Dynamic study about metal release from titanium miniplates in maxillofacial surgery.

It has been shown that titanium (Ti) has had dramatic success in many surgical procedures as a result of its excellent mechanical properties and resistance to corrosion. There is still concern, however, about the release of metal and controversy surrounding whether or not the plates should be removed after bone healing. This study has been conducted to investigate whether or not there is a relationship between duration of plating and metal release from Ti miniplates in maxillofacial surgery. A prospective cohort study design was used. The concentration of Ti, in the soft tissues covering the plates, was examined in all patients who underwent removal of Ti miniplates from January 1998 to April 1999 (51 cases). Inductively Coupled Plasma-Optical Emission Spectrometry was used to measure Ti. Total ti and soluble Ti levels were compared to duration of plating (ranged from 15 days to 3 years, mean = 8 months). Correlation coefficients and two-way ANOVA were data processed. The average amount of total Ti in the soft tissues surrounding the plates was 1306 micrograms/g dry tissue. The mean of soluble Ti was 0.53 microgram/g dry tissue. The results of this study do not support the existence of a relationship between duration of plating and total Ti (correlation coefficient = 0.093 (P > 0.1) nor soluble Ti (correlation coefficient = 0.009 (P > 0.1) in the soft tissue surrounding the plates. Moreover, the only independent factor of Ti release found was associated with mechanical constraints during surgery. Almost 100% of Ti is released during the osteosynthesis. Then Ti levels remain constant in the surrounding tissues. Most of the time, Ti seems to be clinically inert. Compared to the possible risks of a second operation, removal of Ti miniplates should not be a routine procedure except in the case of complaints from patients, particularly in the case of infection, hypersensitivity, dehiscence or screw loosening.

Ferrocyanide ingestion may cause false positives in cyanide determination.

CASE REPORT: The authors present a patient who ingested a cyanide containing solution and arrived at the hospital without any clinical evidence of intoxication but an elevated blood cyanide level. The authors explain this discrepancy with the following hypotheses: 1) the patient ingested cyanide as an iron-chelated complex; and 2) the sulfuric acid used in the standard microdiffusion technique released cyanide from its iron-bound state to result in the observed elevated blood cyanide. Through a series of in vitro analyses, the authors demonstrate the following: 1) the ingested solution tested positive for cyanide with the sulfuric acid technique and negative for cyanide with acetic acid; 2) the presence of a ferrous salt in the ingested product by a colorimetric redox titration technique; and 3) release of a small fraction of the total cyanide from ferrocyanide by the sulfuric acid technique. The authors conclude: 1) the patient ingested potassium ferrocyanide; and 2) the strong acid used in the cyanide microdiffusion assay will liberate cyanide that is chelated to iron to yield false positive results.

[Ecstasy and its "counterparts"]. / L'ecstasy et ses "sosies".

RISK AWARENESS: Use of psychostimulants is spreading in France, particularly at "techno" dances. The generic term "ecstasy" covers a wide variety of molecules with variable formulations. The situation is a true public health problem, generally concerning very young subjects who must be informed of the risks involved. Knowledge of the chemical makeup of the products currently used is needed to provide valid information and reduce risks. CHEMICAL ANALYSIS: Two types of chemical analysis are used for rapid controls. A coloration test is used by the Rave mission implemented by "Médecins du Monde". More elaborate analysis methods are used to identify the active substances and quantify the compounds in the different "tablets". FINDINGS: Rapid controls give a means of quickly identifying samples containing methylenedioxyamphetamines and distinguishing them from other samples which may contain any number of substances with unknown toxicity. A precise analysis of 73 samples has shown highly variable compositions with 22% actually containing methylenedioxyamphetamines. PREVENTION: Precise analytical knowledge of the drugs circulating in "techno" dances has revealed the extreme danger of a large number of the substances used. A continuous control of ongoing consumption is required to correctly warn the users and reduce risk.

[Risk of underestimating blood carbon monoxide by certain analytic methods]. / Risque de sous-estimation de l'oxycarbonémie lié à certaines méthodes de mesure.

OBJECTIVE: Study the effect of delay to assay on the measurement of carboxyhemoglobin (HbCO) in total blood samples. METHODS: Carbon monoxide (CO) and carboxyhemoglobin were measured on 75 blood samples drawn from healthy subjects (smokers and non smokers) and in subjects with carbon monoxide (CO) poisoning. Blood samples were drawn on lithium heparinate in perfectly closed tubes with no head space and stored at 4 infinity C until assay. The samples were pooled into 4 classes for 4 delays to assay: immediate, less than one hour, 3 hours, 12 hours. Infrared spectrometry was used to assay CO and order 4 and 5 derived spectrophotometry using CO-oximeters (AVL 912, IL 482, Corning 270, Radiometer OSM 3, Radiometer ABL 520) for HbCO. RESULTS: Regression lines for CO versus HbCO suggested that oxycarbonemia was underestimated using techniques measuring HbCO. This underestimation varied from 3 to 40% for delays to assay of 0 to 3 hours. CONCLUSION: Clinicians should be aware that the underestimation in oxycarbonemia related to HbCO assays is sensitive to delay to assay.

Acute selenium poisoning.

Reports of acute human selenium toxicity are rare. We report 2 new cases. One patient ingested a mouthful of selenic acid (30 g/L); he only suffered mild gastrointestinal disturbances. Serial measurements of plasma selenium concentrations were performed. The first plasma level was obtained 3 h after ingestion and was the highest (931 micrograms/L); plasma concentrations subsequently decreased with a half-life of 17.5 h. The second patient ingested 1.7 g of sodium selenite. He suffered severe gastroenteritis, had transient electrocardiographic changes and developed a slight elevation of serum bilirubin. The first serum concentration measurement was performed 3 h after ingestion; the selenium level was 2.716 micrograms/L. These data are compared to those from other published cases. The prognostic significance of the blood selenium concentration is discussed.

[Determination of drugs for the diagnosis and the surveillance of acute poisoning]. / Dosage des médicaments pour le diagnostic et la surveillance des intoxications aiguës.

Acute drug poisonings are the first cause of hospital admission among in individuals less than 30 years of age in developed countries. In order to face this problem, an analytic process, including two steps, is proposed; first, a qualitative step leads quite quickly to a medical diagnosis; second, a quantitative step, in close collaboration with the clinician, allows a well adapted reanimation. The result is that the patient receive a quicker and more efficient treatment. Both the analyst and the clinician must know the limits and the requirements of such techniques.

Effects of mode of inhalation of carbon monoxide and of normobaric oxygen administration on carbon monoxide elimination from the blood.

1. The half-life of carbon monoxide (CO) in blood was studied retrospectively in 26 fire victims and in 19 cases of CO poisoning. Normobaric oxygen therapy was administered via mechanical ventilation in 19 fire victims, and by facial mask to the rest of the casualties. 2. Arterial pH was significantly lower (P < 0.05) and PaO2 significantly greater (P < 0.01) in the mechanically ventilated fire victims compared to the spontaneously breathing fire victims. 3. The blood CO half-lives were 91 +/- 38 min for the 26 fire victims and 87 +/- 40 min for the 19 pure CO intoxications. 4. The blood CO half-lives were 92 +/- 40 min for the 19 mechanically ventilated fire victims and 87 +/- 37 min for the 26 spontaneously breathing subjects. 5. We conclude that the elimination of CO from blood was a slow process with no significant effects on the blood CO half-life of either the cause of the CO poisoning or the mode of normobaric oxygen therapy. These data suggest that enhancement of the elimination of carbon monoxide by normobaric oxygen in both pure CO poisoning and fire victims is more difficult to achieve and more complex than has previously been reported.

Cardiovascular repercussions of seizures during cyclic antidepressant poisoning.

Cyclic antidepressant overdose involves a risk of generalized seizures and cardiovascular disturbances. We have conducted a retrospective study to test the hypothesis of a relationship between generalized seizures and the onset of arrhythmia, hypotension or cardiac arrest during cyclic antidepressant intoxication. Patients who had seizures after ingestion of toxic amounts of tri- or tetracyclic antidepressants were included. Limb-lead QRS complex duration and systolic blood pressure were recorded before and after seizure. Twenty-four of the 388 patients (6.2%) who were admitted to our ICU over a four-year period had seizures (2.3 +/- 2 seizures/patient). Cardiac repercussions of cyclic-induced seizure were frequent and severe. In the postictal period, broadening of the QRS duration or hypotension occurred or were exacerbated in at least 41% and 29% of cases, respectively. In three patients (12.5%), the seizure-induced cardiovascular state was life-threatening and required massive alkalinization therapy and vasopressors, and two of the three required cardiac massage or cardioversion. Prior to seizure, these three patients had severe intoxications characterized by QRS duration > or = 120 ms and systolic blood pressure < or = 80 mm Hg. The results of this work confirm the potential risk of cardiovascular deterioration after cyclic antidepressant-induced seizure and raise the question of a prophylactic approach especially towards the subgroup with unstable hemodynamic status.

Determination of hydroxocobalamin and cyanocobalamin by derivative spectrophotometry in cyanide poisoning.

Hydroxocobalamin (OHCo) and cyanocobalamin (CNCo) are determined directly in biological media, without extraction, by using first derivative spectrophotometry. We diluted 200 mL of plasma, urine, or standards with 1.8 mL of pH 6 buffer (boric acid, potassium dihydrogen orthophosphate, and potassium hydroxide). The first derivative spectra of the dilutions were plotted between 320 and 400 nm. At the exact zero-crossing point for hydroxocobalamin, the derivative values of cyanocobalamin concentration were determined. The same procedure was followed for hydroxocobalamin at the zero-crossing point for cyanocobalamin. The derivative values of the concentration curves are linear in the range 5-100 microM. The minimum detection limit is approximately 5 microM for hydroxocobalamin of cyanocobalamin on the determination of hydroxocobalamin or vice versa, although the spectra strongly overlap. The method is fast and simple to use, thus making it easy to assess the in vivo transformation of hydroxocobalamin into cyanocobalamin after the administration of high doses of hydrocobalamin in cyanide poisoning.